This document provides information about two types of systemic mycoses: histoplasmosis and Madura mycosis. Histoplasmosis is caused by the fungus Histoplasma capsulatum and can manifest as pulmonary or disseminated disease. It is diagnosed through microscopy, culture, serology and antigen detection. Treatment involves antifungals like amphotericin B and azoles. Madura mycosis is a chronic infection of subcutaneous tissues that forms sinuses. It is caused by fungi or actinomycetes and is characterized by swelling, nodules and discharging sinuses. Diagnosis involves microscopy and culture of exudates or biopsy specimens. Treatment involves antibiotics, antifung

1. MEDICAL MICROBIOLOGY
ASSIGNMENT
SYSTEMIC MYCOSIS
• HISTOPLASMOSIS
• MADURA MYCOSIS
SUBMITTED TO,
HELEN SHEEBA MA’AM
DEPARTMENT OF MICROBIOLOGY
SUBMITTED BY,
VAISHNAVI V
II MSC MICROBIOLOGY
190268

2. MYCOSIS
• Mycosis: infectious disease caused by pathogenic fungus in humans
and animals.
• Mycoses are common and a variety of environmental and
physiological conditions can contribute to the development of fungal
diseases.
• Other names: mycoses, fungal disease, fungal ...
• Causes: Pathogenic fungus
• Specialty: Infectious Diseases

3. CLASSIFICATION OF MYCOSIS
SUPERFICIAL MYCOSES
• Superficial mycoses are limited to the outermost layers of the skin
and hair. An example of such a fungal infection is Tinea versicolor
• effect specially chest,back,and upper arms and legs.
CUTANEOUS MYCOSIS
• Cutaneous mycoses extend deeper into the epidermis, and also
include invasive hair and nail diseases.
• The organisms that cause these diseases are called dermatophytes.

4. SUBCUTANEOUS MYCOSES
• Involve the dermis, subcutaneous tissues and muscle.
• Chronic ;can initiated by piercing trauma to skin allows fungi to enter.
• Difficult to treat and may require surgical interventions
SYSTEMIC MYCOSES DUE TO PRIMARY PATHOGENS
• Originate primarily in the lungs and may spread to many organ systems
• In general primary pathogens that cause systemic mycoses are dimorphic
SYSTEMIC MYCOSES DUE TO OPPORTUNISTIC PATHOGENS
• Infections of patients with immune deficiencies e.g AIDS
• Examples of opportunistic mycoses include Candidiasis and Aspergillosis.

5. HISTOPLASMOSIS

6. INTRODUCTION
Histoplasmosis also known as:  "Cave disease,"  "Darling's disease,"
 "Ohio valley disease,”  "reticuloendotheliosis,"  "spelunker’s lung"
and  "caver's disease" caused by fungus Histoplasma capsulatum.
present in histiocytes, that is, connective tissue macrophages, in the
RE system, where darling described a capsule in the stained tissue
section.
hepatosplenomegaly is the primary sign in children, while in adults,
histoplasmosis appears as pulmonary disease.
Symptoms of this infection vary but disease affects primarily the
lungs.
 Occasionally, other organs are affected; this is called disseminated
histoplasmosis, and it can be fatal if left untreated.

7. Histoplasma capsulatum

8. CHARACTERISTICS
• Member of the phylum Ascomycota
• Worldwide distribution
• Naturally found in fecal-contaminated soils
• Birds and bats appear to be reservoirs
• Etiologic agent of histoplasmosis
• Dimorphic fungus – Sexual multi-cellular saprophytic mycelia –
Asexual single-celled parasitic yeast

9. • Mycelial form is most commonly found in the environment
• Heterothallic species
• Tightly coiled septate hyphae (A) • Globose cleistothecia (C) • Pear-shaped
asci (E) • Smooth, hyaline, spherical ascospores (F)
• Yeast form is the infectious agent in humans
• Form asexual macro- and microconidia – Also borne by hyphae in the
mycelial form (B) • Conidia germinate via non/polar budding • Yeast cells
have white, thin-walled, oval bodies (A)

10. MORPHOLGY
● In cultures : Grows as mycelial form;
● In body tissues : neither buds nor produces mycelia.
● Spherical structures (spherules) with thick walls and a diameter of
15–60 micro meter, each filled with up to 100 spherical-to-oval
endospores.

11. Histoplasma capsulatum on skin

12. HISTOPLASMOSIS-TYPES
• 2 major forms of histoplasmosis – Pulmonary and disseminated
• Pulmonary histoplasmosis occurs when microconidia or mycelial
fragments are inhaled – Form lesions in the hilar and/or mediastinal
nodes
Many types of pulmonary histoplasmosis
• Asymptomatic pulmonary histoplasmosis
• Acute pulmonary histoplasmosis
• Mediastinal granuloma
• Fibrosing mediastinitis
• Chronic cavitary pulmonary histoplasmosis

13. • Disseminated Histoplasmosis
• Occurs primarily in immunocompromised individuals
In healthy individuals, H. capsulatum is similar to tuberculosis
• While the infection is usually resolved, the fungus is still present
• Constantly kept in check by T lymphocytes
• In immunocompromised individuals, H. capsulatum is able to spread
from the lungs into other organs
• Patients display fever, malaise, and occasionally petechiae or skin
lesions (cutaneous histoplasmosis)
• Tests often reveal mucous membrane ulcerations, simultaneous
enlargement of the liver and spleen, and enlarged lymph nodes

14. HISTOPLASMOSIS CLINICAL
• • Chronic pulmonary histoplasmosis (1/100,000) – pre-existing structural
lung defect, i.e. COPD, emphysema – chronic pneumonia or infection in
cavities, increased sputum – reactivation or reinfection – apical infection,
may be cavitary
• Mediastinal granulomatosis and fibrosis – fibrosis, traction, occlusion of
mediastinal structure
• Histoplasmoma – Fibrocaseous nodule – Concentric caseation and
calcification
• Presumed ocular histoplasmosis syndrome – choroiditis - active or inactive
• may result in visual loss due to macular involvement

16. LABORATORY DIAGNOSIS
• 1. Obtain appropriate specimens sputum bone marrow blood lesion
scrapings urine biopsy specimens
• 2. Direct Examination • Tissue Specimens – stains for fungi - PAS, GMS,
Giemsa – routine histology - H & E - small yeast (2-4 ) intracellular in
macrophages - granulomas - non-caseating - caseating • Sputum - KOH or
calcofluor
• Direct detection methods – Giemsa or Wright’s stains – Calcofluor white
stain, histological stains – Look for small intracellular yeast cells
3. Culture Sabouraud’s agar White - brown mould Typical microscopic
morphology Slow growth 2-8 weeks Rapid ID confirmation Exo-antigen
Molecular probe Traditional ID confirmation Conversion mould to yeast
Animal inoculation

17. 4. Serology – Sensitivity and specificity vary according to stage and
form of disease • Lowest for early acute pulmonary and disseminated
(sensitivity 5-15% at 3 weeks) • Highest for chronic pulmonary and
disseminated (sensitivity 70-90% at 6 weeks) – Complement fixation
test (CFT) • Yeast (more sensitive) and mycelial (histoplasmin) phase
antigens required • ≥1:32 or 4-fold rise suggests recent infection • X-
reactions with B. dermatitidis and C. immitis
• Immunodiffusion – More specific, less sensitive – M bands • Prior
exposure • Acute and chronic diseases • X-reactions occur with other
fungi – H bands • Diagnostic of acute disease • Revert to negative in 6
months • Acute or chronic • Little cross-reaction with other fungi •
Appear later than CFT Abs • ELISA/RIA – Increased sensitivity (90%
active pulmonary histo) – Decreased specificity compared to CFT

18. • Ag detection – Urine – Most useful in patients with large fungal
burden • Acute pulmonary histo (80% sensitive) • Progressive
disseminated histo (90% sens) – Less useful with lower fungal burdens
• Chronic pulmonary (15% sensitive) • Subacute pulmonary (30%
sensitive) – Serum sensitivity is lower – Cross-reactions with B.
dermatitidis and recipients of anti-thymocyte globulin – Joe Wheat,
MiraVista Diagnostics, Indianapolis

19. TREATMENT:
• Amphotericin B: Intravenous drug
• Itraconazole: oral drug
• ketoconazole
• Fluconazole
• Veroconazole
• Pasaconazole
• Supportive therapy and rest
PREVENTION AND CONTROL:
• Safety measure during exposure to bats or bird dropping
• Minimize exposure to endemic areas

20. MADURA MYCOSIS

21. INTRODUCTION
• Madura foot or mycetoma (tumour-like)
• Chronic granulomatous disease characterised by localised infection of
subcutaneous tissues and sometimes bone characterised by
discharging sinuses filled with organisms like actinomycetes or fungi.
HISTORY
• Gill first described the disease in the Madura district of India in 1842.
• Hence the term Madura foot.

22. PATHOPHYSIOLOGY
• Typically present in agricultural workers(hands shoulders and back –
from carrying contaminated vegetation and other burdens).
• Individuals who walk barefoot in dry , dusty conditions
• People who work in rural areas where they are exposed to acacia
trees or cactus thorns containing the etiologic agents.
• Spread occurs through skin facial planes and can involve the bone.
• Two thirds arise on the foot , but can involve the hands , back or
shoulders.

23. • Following initial injury , the disease – follows a slow chronic course
over many years with painless swelling and intermittent discharge of
pus.
• There may be a deep itching sensation
• Pain may occur due to secondary bacterial infection or bone invasion
• After some years, massive swelling of the area occurs , with
induration , skin rupture and sinus trace formation. As the infection
spreads, old sinuses close and new ones open
• Sinus discharge

25. CAUSES
• Due to fungi – eumycetoma (40%) or • Actinomycetes –
(actinomycetoma) 60%
• Actinomycetoma may be due to Actinomadura madurae
Actinomadura pelletieri Streptomyces somaliensis Nocardia species
• Eumycetoma is often due to
 Madurella mycetomi ,
Pseudallescheria boydi (Scedosporium apiospermum) ,
 Cladophialophora

27. CLINICAL FEATURES
• Slow spreading skin infection
• Local swelling
• Small hard painless nodules
• Ulceration • Pus discharge
• Scarred skin & discoloration
• Itching
• Pain and burning sensation

28. LAB STUDIES
• Direct microscopy
• Blood – leukocytosis & neutrophilia
• Culture of exudates
• Skin biopsy
• Serology
• DNA sequencing has been used for identification in difficult cases.

29. MICROSCOPY
• Serosanguinous fluid containing the granules examined using – 10%
KOH and Parker ink or calcofluor white mounts
• Tissue sections stained using H&E(Hematoxylin and Eosin stain) ,
PAS(Periodic Acid Shiffs Stain) and Grocott’s methenamine silver(GMS).
• Actinomycotic grains contains very fine filaments.
• Fungal grains contain short hyphae (branched filaments) that are
often swollen

30. CULTURE
• Sabouraud’s dextrose agar or mycobiotic agar to isolate fungi
• Blood agar to isolate bacteria
• Agar plates are cultured at 25-30 degree celcius and 37 degree celcius
for up to six weeks . Fungi grow more quickly than actinomycetes.

31. SEROLOGY
• (1) Immunodiffusion tests eumycotic mycetoma infections.
• (2) Counterimmunoelectrophoresis
• (3) Enzyme-linked immunosorbent assay (ELISA)
• (4) Western blot.

32. IMAGING
• Plain x-rays assess for evidence of bone involvement
• CT scan may be more sensitive in the early stages
• MRI scans better assessment of the degree of bone and soft tissue
involvement; and may be useful in evaluating the differential diagnosis
of the swelling .

33. BONE RADIOGRAPHY
• Once mycetoma has invaded the bone, the following changes may be
observed:
• Cortical thinning is due to compression from the outside by the
mycetoma.
• Multiple lytic lesions or cavities may be large and few in number with
well-defined margins (eumycetoma) or small and numerous with ill
defined margins(actinomycetoma).
• Osteoporosis may occur in late stages.

35. ULTRASONOGRAPHY
• Single or multiple thick-walled cavities with hyper reflective echoes
and no acoustic enhancement
• In eumycetoma, the hyper reflective echoes are sharp, corresponding
to the grains in the lesion.
• In actinomycetoma, the hyper effective echoes are fine and closely
aggregated and commonly settle at the bottom of the cavities.

36. TREATMENT
• Due to the slow ,relatively pain –free progression of the disease,
mycetoma is often at an advanced stage when diagnosed.
• Antifungals
• Antibiotics
• Treatment of any secondary infections
• Amputation-in severe cases

37. • Treatment for eumycetoma is primarily surgical, and often combined
with antifungal agents such as itraconazole, fluconazole and
posaconazole.
• Treatment for actinomycetoma is primarily medical, with antibiotics
such as sulfonamides, aminoglycosides or carbapenems, among others.
There is no sole consensus on ideal antibiotic therapy, but it should be
tailored to the causative organism and clinical response. Surgery may
be indicated in severe cases.

38. SURGICAL
• Excision of the affected tissues
• Localized mycetoma lesions that can be excised completely without
residual disability.
• Disease process more extensive than suggested by superficial lesion-
so apparently healthy tissue removed to avoid recurrence
• Surgical reduction of large lesions can improve the patient’s response
to medical treatment.

39. COMPLICATIONS
• Secondary bacterial infection
• Immonucompromised patients may can develop invasive infection
• This can cause increased pain and disability as well as osteomyelitis,
septicaemia, which my be fatal if untreated.
• Lymphatic obstruction and fibrosis may cause lymph oedema
• In advanced cases, deformities or ankylosis may occur
• Chronic neglected infection may necessitate amputation.

41. EPIDEMOLOGY
• Endemic in the tropics and subtropics
• More common in men than in women
• The male-to-female ratio is 3:1
• Particularly those aged 20 to 50